FOR IMMEDIATE RELEASE: March 28, 2014
Contact: Rachael Kagan, Department of Public Health
415 420-5017 cell, 415 206-3170 desk or firstname.lastname@example.org
UCSF INDEPENDENT REVIEW OF SAN FRANCISCO GENERALHOSPITAL SECURITY PROGRAM COMPLETED
Recommendations for infrastructure, continuing improvements
SAN FRANCISCO – The Department of Public Health announces that the independent review by UCSF Medical Center of San Francisco General Hospital and Trauma Center’s security program is completed and was presented to Mayor Edwin Lee today.
The review, conducted from October 2013 to March 2014, took a comprehensive look at the hospital’s security program and produced recommendations for consideration by the City.
“I would like to thank UCSF for this extremely thorough and helpful independent review and evaluation that we can now use to make sure that San Francisco General meets the highest standards of security for all San Franciscans,” Mayor Lee said. “San Francisco General is a great public hospital that we rely on every day, for all our residents and visitors. We must ensure that the security matches the excellent quality medical care at SFGH.”
The review recommends that San Francisco General Hospital (SFGH) take steps to strengthen the infrastructure to support outstanding security, such as appointing a full-time Hospital Security Program Manager, providing additional space for a comprehensive Security Operations Center and investing in security equipment and technology.
“The review creates a road map for us as we continue to improve security,” said Barbara Garcia, Director of Health. “It lays out a path to achieve state-of-the-art security for our patients, visitors and staff. The independent review gave us exactly what we need to plan next steps.”
Of note, several of the recommendations are already underway. These include developing a comprehensive security management plan, orientation and training program, and developing a security check-list to be part of regular environment of care rounds.
Additionally, the new acute care building currently under construction at SFGH will have stronger security features from day one, including enhanced surveillance cameras and tighter access controls.
“We welcome this review by a neighboring hospital and thank them for sharing their expertise and insights with us,” said Sue Currin, RN, MSN, CEO of San Francisco General Hospital. “We have already made significant progress on many of the recommendations. We also benefit from new ideas and suggestions that will be helpful going forward to deliver the most secure campus for all our patients, staff and visitors.”
The recommendations regarding security operations, which are carried out by the San Francisco Sheriff’s Department (SFSD) under contract by the Department of Public Health (DPH) sites throughout the City, include establishing a formal relationship with a certified 911 call center for emergencies, defining security staffing and performance metrics, and improving communication between the Sheriff’s Department and DPH and hospital leadership.
The independent review by UCSF Medical Center was requested by Mayor Lee after the tragic death of SFGH patient Lynne Spalding Ford. That tragedy was rigorously investigated by state and federal health care regulators. In January, the federal Centers for Medicare and Medicaid Services verified the hospital’s compliance with its Plan of Correction toimprove the hospital’s ability to address security issues and improve safety.
The UCSF Medical Center independent review was not an additional investigation, but rather took a global look at the security program for the entire hospital campus.
“With the independent review, we were able to go the extra mile on behalf of our patients, staff and visitors,” Currin said. “We are already a safer organization today, and we will study these recommendations to learn how we can make further improvements.”
The review notes several improvements that already have occurred:
- Daily (emergency) stairwell checks, door alarms converted to continuous audible alarms requiring deactivation; and charge nurse checks for all patients when alarms are activated;
- Development of a Missing Patient Policy and Procedure including a house-wide “Code Green” announcement and search protocols;
- Assignment of a Sheriff’s Captain to SFGH as the on-site Institutional Police Unit Commander; the Captain is having weekly meetings with the hospital CEO and monthly meetings with the Public Health Director;
- Two SFSD Lieutenants were assigned to SFGH as site commanders providing 7-day per week supervision;
- SFSD Training Officer was assigned to SFGH;
- An orientation and training program was established and completed for all 46 assigned Deputy Sheriffs at SFGH;
- SFSD developed a six-week training course of DPH sites that is being implemented;
- Examination of the MOU (Memorandum of Understanding) between SFGH and the Sheriff’s Department has begun for the provision of security services;
- (Revised) SFGH’s Security Management Plan;
- SFSD has reviewed resources available through the International Association of Hospital Safety and Security (IAHSS) website;
- The policy on the Close Observation of the Hospitalized Patient was revised to clarify communication, triggers for patient evaluation and documentation of physician orders and actions.
FOR IMMEDIATE RELEASE: March 21, 2014
Contact: Rachael Kagan, Department of Public Health
415 420-5017 cell, 415 206-3170 desk or email@example.com
DEPARTMENT OF PUBLIC HEALTH PATIENT INFORMATION INVOLVED IN SECURITY BREACH
Billing contractor’s computers stolen, containing personal data
SAN FRANCISCO — A February 5 break-in at the Torrance, CA office of Sutherland Healthcare Solutions resulted in the theft of computers that included patient information from Sutherland clients, including the San Francisco Department of Public Health (DPH).
Sutherland, which contracts with DPH to provide billing services, informed DPH on March 18 that personal information of approximately 55,900 San Francisco medical patients was stolen, including names, billing information, and in some cases social security numbers, dates and locations of services and dates of birth. The majority of patients were cared for at DPH facilities between August 2012 and November 2013.
“We take the security and privacy of patient information very seriously,” said Barbara Garcia, Director of Health. “We are working to ensure that all patients are notified and provided with resources to help them protect their privacy.
There is no confirmation that there has been any attempted access or attempted use of the information involved in this incident. The health department will begin contacting affected patients by mail next week. In cases where a mailing address is not available, the department is conducting outreach to find and notify the individuals. The California Department of Public Health, the California Attorney General and federal authorities have been alerted.
Sutherland is offering San Francisco patients free credit monitoring and recovery services for one year with identity theft insurance coverage of up to $20,000. Starting on Monday March 24, patients may call Sutherland’s call center at 866-486-4809 or visit http://www.myidcare.com/idexpertshealthcareprotection to learn if they are affected and to access these services.
Records of approximately 168,500 patients of Los Angeles County departments of health services and public health also were stolen in the break-in. The criminal investigation is being led by the Torrance Police Department.
The San Francisco patients had used the outpatient medical services of the Health Department’s Community Oriented Primary Care Clinics or of the San Francisco General Hospital and Trauma Center emergency department or clinics. Most of them were uninsured.
Sutherland is a business processes and technology management services company based in Rochester, NY. As a contractor, Sutherland is obligated by the federal Health Insurance Portability and Accountability Act (HIPAA) to protect patient privacy. Sutherland has informed DPH how they are ensuring that patient information is secure and what steps they are taking to prevent an incident like this from happening again. Sutherland’s response includes:
- Encrypting all computers
- Requiring all data be saved to share drives and not be saved on individual computers
- Cabling desktop computers to desks
San Francisco General Hospital and Trauma Center
Statement on Improved Safety and Security by Sue Currin, RN, MSN, CEO
Changes Validated by Federal Inspection
January 24, 2014
San Francisco General Hospital and Trauma Center reports that the federal Centers for Medicare and Medicaid Services (CMS) has verified our compliance with our Plan of Correction (POC) to fix the problems that contributed to the tragic death of patient Lynne Spalding Ford, and that we have made significant progress toward a safer and more secure hospital. Her family is in the forefront of our minds as we continue to work to improve safety and security for all our patients.
CMS conducted a thorough investigation from October 30 to November 8 2013, following the hospital’s self-reporting of Ms. Spalding’s death. The survey covered general security, patient safety/security and privacy. The federal investigators returned this week to re-survey the hospital. The surveyors completed staff interviews, observed practice in the patient care areas, and reviewed documents before concluding that SFGH is in compliance with all requirements.
Many of the changes outlined in the POC already have been implemented and we can assure Ms. Spalding’s family, and all our patients, visitors and staff, that we are a safer organization today.
Working in collaboration with the San Francisco Sheriff’s Department, which provides security on the San Francisco General Hospital (SFGH) campus, we have made significant improvements in the key problem areas identified during the investigations: general security, patient safety/security and privacy.
General Security Improvements:
- Safer stairwells:
Security checks of all emergency stairwells are completed daily by Sheriff’s staff.
Emergency stairwell door alarms were converted to continuous audible alarms requiring deactivation with a key.
Security checks by Sheriff Deputies are triggered when a stairwell alarm rings.
Charge nurses check to ensure all patients are accounted for when a stairwell alarm rings near a patient care unit.
- Monthly meetings between the Sheriff and Department of Public Health Director.
- Weekly meetings between San Francisco Sheriff Department (SFSD) leadership and SFGH CEO are held to review ongoing security measures and the status of the POC.
- Sheriff’s Captain Kenneth Ferrigno assigned to SFGH as the on-site Institutional Police Unit (IPU) Unit Commander.
- Two SFSD Lieutenants assigned as SFGH Site Commanders providing 7-day per week supervision.
- SFSD Training Officer assigned to SFGH.
- All 46 SFSD staff at SFGH completed SFGH orientation and training on new security and safety procedures.
- SFSD developed a six-week training course for Department of Public Health sites that is being implemented.
- SFSD policies and procedures for IPU operations at SFGH were reviewed and revised.
Patient Safety/Security Improvements:
- The hospital’s policy on AWOL and AWOL At-Risk Patients was strengthened when the Sheriff agreed to include in searches patients who exhibit behavior that concerns the clinical staff as to their state of mind. The policy includes a script for staff to follow to ensure accuracy when reporting an at-risk patient leaving the hospital before their treatment is completed. The Sheriff also developed consistent and comprehensive search procedures for missing at-risk patients on our hospital campus.
- The hospital developed, implemented and trained all staff on an organizational response called Code Green when a hospital-wide search is needed to locate an at-risk patient. Sheriff and hospital staffs work collaboratively when campus wide searches are needed.
- The hospital has created a new Patient Tracking System policy and procedure for patients who are at-risk of leaving their units. The hospital has purchased a tracking system that we plan to begin using next month for patients who meet the criteria.
- The policy on the Close Observation of the Hospitalized Patient was revised to clarify required nurse and physician communication, triggers for patient evaluation, and documentation of physician orders and actions instituted to keep patients safe. We learned that for these patients, whose status can vary multiple times during their hospitalization, we had weaknesses in the areas of consistent documentation and communication of these changes and revisions to their care plan. Staff are being retrained and audited to ensure that these vulnerable patients get the care they need.
Privacy policies were effective and enforced:
- SFGH takes patient privacy extremely seriously and as such we conduct routine audits of medical records of high profile patients. During such an audit on October 21, we discovered four instances when hospital staff accessed Ms. Spalding’s medical record without authorization. This is unacceptable.
- We fully enforced our privacy policies to discipline the staff involved. All were placed on administrative leave immediately while an investigation took place. Since then, one has resigned, two have been terminated and one has returned to work.
- We reported these privacy breaches to the CA Department of Health and to Ms. Spalding’s family.
- There was an additional privacy violation by a member of the Sheriff’s Department staff at SFGH, who spoke on a recorded phone line about Ms. Spalding on the day she was found. Out of respect for Ms. Spalding’s family, we must clarify that the information given was not true. Even so, it still violated her privacy. We apologize for any additional hardship this may cause. That employee no longer works at SFGH or at any Department of Public Health site.
Ongoing independent review of SFGH security systems by UCSF continues. It includes:
- Evaluation of SFGH security system controls (e.g. cameras, alarms, panic buttons, exits).
- Review of policies and procedures related to patient, staff and visitor safety and security.
- Evaluation of SFGH campus security resources (staffing model, hours of service, post and patrol areas, job duties, training and job classifications assigned).
What happened to Ms. Spalding was horrible and never should have happened. We have worked diligently to fact find, cooperated with multiple investigations and developed a plan to become a safer, more secure organization. This is not simply about passing inspection. It is about the memory of Lynne Spalding Ford, our patient, and the tragedy that occurred on our campus. We want everyone in San Francisco to be assured that we take this very seriously and have taken significant steps to improve. Patient safety is our top priority.
With the support of Mayor Ed Lee, Director of Health Barbara Garcia and Sheriff Ross Mirkarimi, SFGH is a stronger organization. As the city’s only trauma center and care provider for more than 100,000 patients and their families each year, we want all our patients to have full confidence that in addition to excellent care, we will also provide a safe and secure environment.
San Francisco General Hospital and Trauma Center (SFGH)
San Francisco GeneralHospital and TraumaCenter is the sole provider of trauma and psychiatric emergency services for the City and County of San Francisco. A comprehensive medical center, SFGH serves some 100,000 patients per year and provides 20 percent of the city’s inpatient care. In 2011, SFGH became the first hospital in the country to be certified for a Traumatic Brain Injury program. As San Francisco’s public hospital, SFGH’s mission is to provide quality health care and trauma services with compassion and respect to patients that include the city’s most vulnerable. General Hospital is also one of the nation’s top academic medical centers, partnering with the University of California, San Francisco School of Medicine on clinical training and research.
Contact: Rachael Kagan (415) 206-3170, (415) 420-5107c or firstname.lastname@example.org
January 7, 2014
STATEMENT ON PATIENT LYNNE SPALDING FORD
by Sue Currin, RN, MSN, CEO of San Francisco General Hospital and Trauma
Everyone at San Francisco General Hospital is shocked and saddened by the tragic death of Ms. Lynne Spalding Ford. Our only focus is on having a safe and secure environment for our patients, staff and visitors and to ensure that this never happens again. In the last three months we have become a safer organization by doing everything we can to learn all of the facts about what went wrong and making immediate changes to our safety and security systems.
The review of the audio tapes related to this event provides additional information as we evaluate our security policies and procedures and make any and all required changes so that our hospital meets the highest standards.
Our improvement work began immediately on October 8th, and continues today. It includes changes such as daily stairwell checks and revised alarm procedures, and contracting with UCSF for a third party, independent review of safety and security systems at SFGH. In addition, the San Francisco Sheriff’s Department, which provides security at the hospital, has instituted staffing, training and communication changes at the hospital.
At the end of this process, SFGH will be a stronger organization. As the city’s only trauma center and care provider for more than 100,000 patients and their families each year, we want all our patients to have full confidence that in addition to excellent care, we will also provide a secure environment.
San Francisco General Hospital and Trauma Center is the sole provider of trauma and psychiatric emergency services for the City and County of San Francisco. A comprehensive medical center, SFGH serves some 100,000 patients per year and provides 20 percent of the city’s inpatient care. In 2011, SFGH became the first hospital in the country to be certified for a Traumatic Brain Injury program. As San Francisco’s public hospital, SFGH’s mission is to provide quality health care and trauma services with compassion and respect to patients that include the city’s most vulnerable. General Hospital is also one of the nation’s top academic medical centers, partnering with the University of California, San Francisco School of Medicine on clinical training and research.
December 13, 2013
STATEMENT ON PATIENT LYNNE SPALDING FORD
by Sue Currin, RN, MSN, CEO of San Francisco General Hospital and Trauma
SAN FRANCISCO — The tragic death of our patient, Lynne Spalding Ford, was a horrible event that should never have happened. Our hearts go out to Ms. Spalding’s family and friends and we are keeping them foremost in our minds as we work to understand what went wrong. Everyone here at San Francisco GeneralHospital is shocked and saddened by Ms. Spalding’s loss. We have been doing everything we can to learn the facts and to ensure that it never happens again.
With the Medical Examiner’s report complete, there is more information now available. We have not yet had a chance to review the report, but we hope that it can help the family and hospital better understand what happened. Although the picture is becoming more complete, we may never know everything about this tragedy, and questions may continue.
Nothing changes the fact that our only focus is on having a safe and secure environment for our patients, staff and visitors. We will do whatever it takes to make that happen, and make any and all required changes so that our hospital meets the highest standards.
Our improvement work began immediately on October 8 and continues today.
An independent review of the safety and security systems at SFGH has already begun. The review, by UCSF, is currently evaluating all hospital security policies and procedures, conducting staff interviews to identify needs and priorities, and soliciting proposals for outside experts to conduct a review of security systems controls, such as cameras and surveillance, entrance and exit access and alarms for SFGH patient care buildings. Next, the independent review will examine security staffing, including job classifications and assignments, hours, job duties, training and post areas.
Other changes already in place at the hospital include:
- Daily emergency stairwell checks by Sheriff deputies.
- We have updated all emergency stairwell door alarms to require deactivation with a key.
- When a stairwell alarm rings, it triggers a security check by Sheriff
- When a stairwell alarm rings, and the stairwell is near a patient care unit, the charge nurse immediately checks the unit to ensure that all patients are accounted for.
The San Francisco Sheriff’s Department, which provides security at the hospital, has instituted the following changes as well:
- All 46 SFSD staff assigned to SFGH completed SFGH new employee orientation and training, include SMART training.
- A full time SFSD Training Officer has been assigned to the SFGH campus
- Captain Ken Ferrigno has been assigned to the SFGH campus full time. He reports directly to the Sheriff as the Institutional Police Unit (IPU) Unit Commander.
- Two full time Lieutenants have been assigned to act as SFGH Site Commanders
- At each shift change (3 times a day, 24/7) the SFSD watch commander conducts a muster meeting – where information regarding current security issues in the hospital is passed along from shift to shift so there is continuity of services
- The SFSD is developing a six week training course specific to working at Department of Public Health sites
At the end of this process, SFGH will be a stronger organization. As the city’s only trauma center and care provider for more than 100,000 patients and their families each year, we want all our patients to have full confidence that in addition to excellent care, we will also provide superior safety and security systems.
San Francisco GeneralHospital and TraumaCenter is the sole provider of trauma and psychiatric emergency services for the City and County of San Francisco. A comprehensive medical center, SFGH serves some 100,000 patients per year and provides 20 percent of the city’s inpatient care. In 2011, SFGH became the first hospital in the country to be certified for a Traumatic Brain Injury program. As San Francisco’s public hospital, SFGH’s mission is to provide quality health care and trauma services with compassion and respect to patients that include the city’s most vulnerable. GeneralHospital is also one of the nation’s top academic medical centers, partnering with the University of California, San Francisco School of Medicine on clinical training and research.
We understand that last week the San Francisco Police interviewed the person they believe to be the witness who saw a person in the stairwell on October 4th.
This witness came forward after seeing a flier that was circulated by the University of California Police, in cooperation with the SFPD, to raise awareness and encourage anyone with information to come forward. The witness is a male, UCSF researcher who works on the SFGH campus. We do not know the content of his interview with the police or what information he was able to provide, if any.
We are very pleased to report this progress in the case. It will get us closer to learning all the facts about what happened to Lynne Spalding, so that we can take whatever steps are necessary to ensure that it will never happen again.
Updates will continue to be posted here and on the SFGH Media Hotline, 206-3376, as information develops.